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Kathleen
I have just read throughly through all the e-mails re the injection debate
and need to respond to your question on private pay assisted living programs
and delegation practices. I am the director/administrator of one such
program and I assure you I do not delegate nursing tasks to my CRMA's. I am
a strong advocate for them and also for the safety of my residents. As I
said in my response yesterday I feel we would be asking too much of our
CRMA's to give injectibles other than the two the regs allow.
As others have said, I too have a very capable staff of CRMA's who provide
wonderful care to our residents, but who are not nurses and frankly most of
them do not want that added responsibility. (They like what they do.)
This is only meant to clarify my practice in a private pay assisted living
program, and I hope does not sound too defensive. I too feel dialogue is
important and helpful.
Thank you for making us think and look at our practices.
Darlene
-----Original Message-----
From: Kathleen Bernard [mailto:voodoosgirl@midmaine.com]
Sent: Monday, December 13, 2004 10:19 PM
To: Mauro, Peter; 'Darlene'; Beas-crma@lists.state.me.us
Subject: Re: beas-crma Fw: sub-cutaneous injections
Hello Everyone-how come we're all alarmed by this, but Peter and Carol
think it's ok. Just wondering....
Peter, when you say "we have allowed the epi to not only cover bee stings
but other issues requiring that med." are you talking about the Lovenox?
Lovenox is a low molecular weight heparin, given for its anticoagulation
effect on blood pre and post surgury. It has extensive contraindications and
precautions and its life-threatening side effect is hemorrhage.
Epinephrine is in the Epi-pen, it is used as a bronchodilator managing
severe allergic reactions. Contraindications and precautions are fewer and
there are no life-threatening side effects from the med.
Insulin is a hormone used to treat diabetes. There are very few
contraindications, precautions and adverse side effects. The
life-threatening side effect is hypoglycemia.
So, all 3 meds are given subcutaneously and that is about the only thing
they have in common. The method of injection is not the issue. Patient
safety is the issue. A monkey can give a SC injection, but the monkey can't
keep the patient safe afterwards. (no offense to the CRMA's)
This is the email I received at work from the director of the home health
division that was denied payment:
"I just heard back from Lorraine LaChappelle at BEAS re: the meeting last
week that looked at CRMA curriculum. In that meeting Lorraine brought up the
Lovenox issue and the licensing regs governing level IV group homes. They
acknowledged that section 7.1.2 and 7.1.3 allow for unlicensed personnel to
administer insulin and bee sting kits only. They feel however, that because
Lovenox is a SQ medication and administered by the same technique that it
could be administered by a CRMA with proper training per sections 7.16 and
7.17 of those same regs. Also, they looked at Chapter 6 of the BON regs
re:teaching an unlicensed person. She said if the group home continued to
have concerns they should call Peter Mauro."
What ever happened to the delegation decision tree? If the task is within
the RN's scope of practice and NOT within the scope of practice of the UAP
then we can not delegate the task. So if one RN decides to delegate and
another RN decides to protect her patient and her license and NOT delegate,
the agency is punished financially if we choose patient safety.
The payment issue for MaineCare is NOT the same issue as the CRMA doing
this type of task. It is one thing to say the fee is "built into" the rate
so the home takes the hit when a nurse is needed. It is another thing to say
we can teach unlicensed people tasks that are beyond their training. If they
want to be nurses, let them go to school and get the degree, license and
debt, like the rest of us.
I realize the BON participated to some extent in the regs but I would like
to present the specifics of how the regs are being interpreted to see what
they think. Anyone have a best friend on the Board?
I keep wondering if the private-pay assisted living homes are delegating
nursing tasks.
Kathleen
----- Original Message -----
From: Mauro, Peter
To: 'Darlene' ; 'Kathleen Bernard' ; Beas-crma@lists.state.me.us
Sent: Monday, December 13, 2004 3:11 PM
Subject: RE: beas-crma Fw: sub-cutaneous injections
Even though the regs are specific about insulin and bee sting, we have
allowed the epi to not only cover bee stings but other issues requiring that
med. Also, at the end of section 7 there is a section which was designed
from the BON in their chapter 6 on coordination and oversight, to take care
of other issues that might come up that would allow RNs to teach unlicensed
personnel. DHHS/BEAS does not dictate that all RNs do this teaching, but if
they feel that the person is competent to learn and competent to carry
through, then they can. Also, DHHS/MaineCare is not going to double pay the
services of homehealth when there is a portion built into the rate for Nurse
services. Those facilities that want to train CRMAs to do some of those
procedures, can, those who want to hire a nurse and pay them out of the
daily rate to do some of those other services can do that. As licensing
moves towards being merge red into one unit, perhaps some of this can and
will be looked at. Carol and I have looked at all inquiries that providers
have had and we deal with over 800 freestanding facilities, to help
alleviate some of these issues.
-----Original Message-----
From: owner-beas-crma@lists.state.me.us
[mailto:owner-beas-crma@lists.state.me.us]On Behalf Of Darlene
Sent: Monday, December 13, 2004 10:40 AM
To: 'Kathleen Bernard'; Beas-crma@lists.state.me.us
Subject: RE: beas-crma Fw: sub-cutaneous injections
Kathleen, I also read the regs as specific to allowing CRMA's to
administer sc insulin and bee sting kits after RN instruction. Anything
further in my opinion, is asking too much from our CRMA's. What does Peter
say about this matter?
Darlene Grass RN
Granite Hill Estates
-----Original Message-----
From: owner-beas-crma@lists.state.me.us
[mailto:owner-beas-crma@lists.state.me.us]On Behalf Of Kathleen Bernard
Sent: Friday, December 10, 2004 11:59 PM
To: Beas-crma@lists.state.me.us
Subject: beas-crma Fw: sub-cutaneous injections
----- Original Message -----
From: Kathleen Bernard
To: Beas-crma@lists.st.me.us
Sent: Friday, December 10, 2004 7:50 AM
Subject: sub-cutaneous injections
Hi Everyone,
I would like to get your feedback on a recent dilemma. I cover 6
group homes under the assisted living regs, PNMI and BDS. One home is a
level IV assisted living home but serves adults with mental illness. We have
CRMA's, one LPN that coordinates appointments and works M-F days.
We needed home health to provide evening SC lovenox which they did
but Medicaid denied their payments. The Medicaid folks feel that CRMA's can
administer this SC medication because the assisted living regs state SC
insulin is ok so the assumption is that SC anything is ok.
Is anyone aware of CRMA's giving anything but bee sting and insulin
injections? The CRMA course seems specific, as do the regulations....bee
sting and insulin with instruction from an RN and not part of the CRMA
course itself.
Through the many levels of conversations about this subject Peter
Mauro's name was mentioned. It is unclear to me at this point what details
were presented to him.
Thanks for any help and guidance.
Kathleen Bernard RN,BC
Community Health and Counseling/Bangor
947-0366 x452
the email is my home, I don't have work email
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